Provider Demographics
NPI:1639491004
Name:RESEDA VILLAGE DENTAL STUDIO
Entity Type:Organization
Organization Name:RESEDA VILLAGE DENTAL STUDIO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-757-7070
Mailing Address - Street 1:18700 SHERMAN WAY STE 116
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-9101
Mailing Address - Country:US
Mailing Address - Phone:818-757-7070
Mailing Address - Fax:818-757-7788
Practice Address - Street 1:18700 SHERMAN WAY STE 116
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-9101
Practice Address - Country:US
Practice Address - Phone:818-757-7070
Practice Address - Fax:818-757-7788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-25
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54191305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA525031OtherMEDI-CAL